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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 280111959
Report Date: 08/16/2021
Date Signed: 08/16/2021 12:38:45 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:GREENHILLS CARE HOME, THEFACILITY NUMBER:
280111959
ADMINISTRATOR:GANTAN, KAMFACILITY TYPE:
740
ADDRESS:115 THAYER WAYTELEPHONE:
(707) 558-8487
CITY:AMERICAN CANYONSTATE: CAZIP CODE:
94503
CAPACITY:24CENSUS: 24DATE:
08/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Kamilee GantanTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Angela Elliott conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Administrator Kamilee Gantan. Facility has 24 residents. Facility offers activities including exercise, music therapy, art and Bingo.

During facility tour, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Administrator indicated facility had a recent Sprinkler Inspection on 8/10/2021. Fire Extinguisher was last inspected on 4/8/2021. Disaster Drills and Emergency Disaster Plan were not available for review. LPA issued Technical Assistance. LPA and Administrator discussed the importance of having documents available for review.

There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations. Dangerous items were stored inaccessible to residents. There was a supply of cleaners, hygiene products and paper products available for residents. Resident bedrooms had required furnishings. Hot water temperatures measured between 105 degrees and 120 degrees F within Title 22 acceptable range.

Facility has submitted a mitigation program plan that has been approved. COVID-19 postings have been placed at facility and entrance has small table with hand sanitizer and other items designated for visitors and staff before coming into the facility. Facility has PPE supplies stored in the main office. Cleaning supplies are kept in a locked utility closet. Facility has a 30-day supply of medication for residents and they are kept in a locked medication cart. All staff had masks on during this visit.

Continued LIC809-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: GREENHILLS CARE HOME, THE
FACILITY NUMBER: 280111959
VISIT DATE: 08/16/2021
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In addition, facility has a designated areas for visitors which are being allowed for scheduled visits. Residents also have available Facetime and telephone calls when contacting family members and others. Staff have received COVID-19 related training and have been N-95 fit tested. LPA issued a Technical Assistance. LPA and Administrator discussed the importance of having training documentation available for review.

LPA advised facility to contact local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + cases in the facility.

LPA had a discussion with Licensee regarding guidelines per PIN-21-32.1. LPA confirmed Licensee gets PIN’s automatically via email.

Administrator certificate 6021878740 expired 8/6/2021. Administrator indicated renewal is still being processed. LPA requested copy of current Administrator certificate when obtained. LPA requested copy of disaster Drill documentation, current Emergency Disaster Plan, COVID-19 training and N-95 fit testing documenation.

No citations issued for deficiencies at this time.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2021
LIC809 (FAS) - (06/04)
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